Failure to Timely Report Sexual Abuse Incident
Penalty
Summary
The facility failed to report an incident of sexual abuse involving two residents within the required two-hour timeframe to the State Survey Agency (SSA), Ombudsman, and local law enforcement. The incident occurred when one resident, while in a wheelchair, inappropriately touched another resident's buttocks and subsequently exposed his genitalia in the presence of the victim and a Certified Nurse Assistant (CNA). The CNA immediately informed the Charge Nurse (CN) of the incident, but the required notifications to authorities were not made until more than two hours after the event. Resident 1, who was the victim, had a medical history including an unspecified injury, open wound to the right knee, anxiety disorder, and effusion of the right ankle, and was determined to have the capacity to understand and make decisions. Resident 2, the perpetrator, had diagnoses of dysphagia, schizophrenia, acquired absence of the left leg above the knee, and anxiety disorder, and also had the capacity to make medical decisions. The incident was witnessed by CNA1, who reported it to the CN, but there was a delay in escalating the report to the appropriate authorities as required by facility policy and state regulations. Interviews with facility staff, including the Director of Nursing (DON), Registered Nurse Supervisor (RN Sup 1), Administrator, CN, and CNA1, confirmed that the incident was not reported within the mandated two-hour window. Facility policy clearly states that all allegations of abuse must be reported immediately, defined as within two hours, to the SSA, Ombudsman, and law enforcement. The delay in reporting was acknowledged by staff during interviews, and documentation confirmed that the notifications were made approximately two and a half hours after the incident occurred.